Chapter 56 / Breast 399

C h a p t e r 56

Breast

ANATOMY OF THE BREAST AND AXILLA

Name the boundaries of the axilla for dissection:

Superior boundary

Posterior boundary

Lateral boundary

Medial boundary

Axillary vein

Long thoracic nerve

Latissimus dorsi muscle

Lateral to, deep to, or medial to pectoral minor muscle, depending on level of nodes taken

What four nerves must the surgeon be aware of during an axillary dissection?

Describe the location of these nerves and the muscle each innervates:

Long thoracic nerve

1.Long thoracic nerve

2.Thoracodorsal nerve

3.Medial pectoral nerve

4.Lateral pectoral nerve

Courses along lateral chest wall in midaxillary line on serratus anterior muscle; innervates serratus anterior muscle

Thoracodorsal nerve	Courses lateral to long thoracic nerve
	on latissimus dorsi muscle; innervates
	latissimus dorsi muscle
Medial pectoral nerve	Runs lateral to or through the pectoral
	minor muscle, actually lateral to the lateral
	pectoral nerve; innervates the pectoral
	minor and pectoral major muscles
Lateral pectoral nerve	Runs medial to the medial pectoral
	nerve (names describe orientation from
	the brachial plexus!); innervates the
	pectoral major

400 Section II / General Surgery
Identify the nerves in the				1.	Thoracodorsal nerve
axilla on the illustration below:				2.	Long thoracic nerve
				3.	Medial pectoral nerve
				4.	Lateral pectoral nerve
				5.	Axillary vein
			4
			3
5		1
		2
What is the name of the				“Winged scapula”
deformity if you cut the long
thoracic nerve in this area?
What is the name of the				Intercostobrachial nerve
CUTANEOUS nerve that
crosses the axilla in a trans-
verse fashion? (Many surgeons
try to preserve this nerve.)
What is the name of the				Axillary vein
large vein that marks the
upper limit of the axilla?

What is the lymphatic drainage of the breast?

What are the levels of axillary lymph nodes?

III

I

II

Lateral: axillary lymph nodes

Medial: parasternal nodes that run with internal mammary artery

Level I (low): lateral to pectoral minor Level II (middle): deep to pectoral minor Level III (high): medial to pectoral minor In breast cancer, a higher level of

involvement has a worse prognosis, but the level of involvement is less important than the number of positive nodes (Think: Levels I, II, and III are in the same inferior–superior anatomic order as the Le Fort facial fractures and the trauma neck zones; I dare you to forget!)

	Chapter 56 / Breast 401
What are Rotter’s nodes?	Nodes between the pectoralis major and
	minor muscles; not usually removed
	unless they are enlarged or feel
	suspicious intraoperatively
What are the suspensory	Cooper’s ligaments
breast ligaments called?
What is the mammary “milk	Embryological line from shoulder to
line”?	thigh where “supernumerary” breast
	areolar and/or nipples can be found
What is the “tail of Spence”?	“Tail” of breast tissue that tapers into the
	axilla
Which hormone is mainly	Prolactin
responsible for breast milk
production?
BREAST CANCER
What is the incidence of	12% lifetime risk
breast cancer?
What percentage of women	75%!
with breast cancer have no
known risk factor?
What percentage of all breast	2%
cancers occur in women
younger than 30 years?
What percentage of all	33%
breast cancers occur in
women older than 70 years?
What are the major breast	BRCA1 and BRCA2 (easily remembered:
cancer susceptibility genes?	BR BReast and CA CAncer)
What option exists to	Prophylactic bilateral mastectomy
decrease the risk of breast
cancer in women with BRCA?
What is the most common	Failure to diagnose a breast carcinoma
motivation for medicolegal
cases involving the breast?

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What is the “TRIAD OF ERROR” for misdiagnosed breast cancer?

What are the history risk factors for breast cancer?

What are physical/anatomic risk factors for breast cancer?

What is the relative risk of hormone replacement therapy?

Is “run of the mill” fibrocystic disease a risk factor for breast cancer?

What are the possible symptoms of breast cancer?

1.Age 45 years

2.Self-diagnosed mass

3.Negative mammogram Note: 75% of cases of

MISDIAGNOSED breast cancer have these three characteristics

“NAACP”: Nulliparity

Age at menarche (younger than 13 years) Age at menopause (older than 55 years) Cancer of the breast (in self or family) Pregnancy with first child ( 30 years)

“CHAFED LIPS”:

Cancer in the breast (3% synchronous contralateral cancer)

Hyperplasia (moderate/florid) (2 risk)

Atypical hyperplasia (4 ) Female (100 male risk) Elderly

DCIS

LCIS

Inherited genes (BRCA I and II) Papilloma (1.5 )

Sclerosing adenosis (1.5 )

1–1.5

No

No symptoms

Mass in the breast

Pain (most are painless)

Nipple discharge

Local edema

Nipple retraction

Dimple

Nipple rash

Chapter 56 / Breast 403

Why does skin retraction Tumor involvement of Cooper’s ligaments occur? and subsequent traction on ligaments

pull skin inward

What are the signs of breast Mass (1 cm is usually the smallest lesion cancer? that can be palpated on examination)

Dimple Nipple rash Edema

Axillary/supraclavicular nodes

What is the most common site of breast cancer?

What are the different types of invasive breast cancer?

Approximately one half of cancers develop in the upper outer quadrants

Infiltrating ductal carcinoma ( 75%) Medullary carcinoma ( 15%) Infiltrating lobular carcinoma ( 5%) Tubular carcinoma ( 2%) Mucinous carcinoma (colloid) ( 1%) Inflammatory breast cancer ( 1%)

What is the most common type of breast cancer?

What is the differential diagnosis?

Infiltrating ductal carcinoma

Fibrocystic disease of the breast Fibroadenoma

Intraductal papilloma Duct ectasia

Fat necrosis Abscess Radial scar Simple cyst

Describe the appearance of	Peau d’orange (orange peel)
the edema of the dermis in
inflammatory carcinoma of
the breast.
What are the screening
recommendations for breast
cancer:
Breast exam	Self-exam of breasts monthly
recommendations?	Ages 20 to 40 years: breast exam every
	2 to 3 years by a physician
	40 years: annual breast exam by
	physician

404 Section II / General Surgery

Mammograms?

When is the best time for breast self-exams?

Why is mammography a more useful diagnostic tool in older women than in younger?

What are the radiographic tests for breast cancer?

What is the classic picture of breast cancer on mammogram?

Which option is best to evaluate a breast mass in a woman younger than 30 years?

What are the methods for obtaining tissue for pathologic examination?

Recommendations are controversial, but most experts say:

Baseline mammogram between 35 and 40 years

Mammogram every year or every other year for ages 40 to 50 Mammogram yearly after age 50

1 week after menstrual period

Breast tissue undergoes fatty replacement with age, making masses more visible; younger women have more fibrous tissue, which makes mammograms harder to interpret

Mammography and breast ultrasound, MRI

Spiculated mass

Breast ultrasound

Fine needle aspiration (FNA), core biopsy (larger needle core sample), mammotome stereotactic biopsy, and open biopsy, which can be incisional (cutting a piece of the mass) or excisional (cutting out the entire mass)

	Chapter 56 / Breast 405
What are the indications	Persistent mass after aspiration
for biopsy?	Solid mass
	Blood in cyst aspirate
	Suspicious lesion by mammography/
	ultrasound/MRI
	Bloody nipple discharge
	Ulcer or dermatitis of nipple
	Patient’s concern of persistent breast
	abnormality
What is the process for	Stereotactic (mammotome) biopsy or
performing a biopsy when a	needle localization biopsy
nonpalpable mass is seen on
mammogram?

What is a needle loc biopsy (NLB)?

Needle localization by radiologist, followed by biopsy; removed breast tissue must be checked by mammogram to ensure all of the suspicious lesion has been excised

What is a mammotome	Mammogram-guided computerized
biopsy?	stereotatic core biopsies
What is obtained first, the	Mammogram is obtained first;
mammogram or the biopsy?	otherwise, tissue extraction (core or
	open) may alter the mammographic
	findings (fine needle aspiration may be
	done prior to the mammogram because
	the fine needle usually will not affect the
	mammographic findings)
What would be suspicious	Mass, microcalcifications, stellate/
mammographic findings?	spiculated mass
What is a “radial scar” seen	Spiculated mass with central lucency,
on mammogram?	/– microcalcifications
What tumor is associated	Tubular carcinoma; thus, biopsy is
with a radial scar?	indicated
What is the “workup” for a	1. Clinical breast exam
breast mass?	2. Mammogram or breast ultrasound
	3. Fine needle aspiration, core biopsy, or
	open biopsy

406 Section II / General Surgery

How do you proceed if the mass appears to be a cyst?

Is the fluid from a breast cyst sent for cytology?

When do you proceed to open biopsy for a breast cyst?

What is the preoperative staging workup in a patient with breast cancer?

What hormone receptors must be checked for in the biopsy specimen?

What staging system is used for breast cancer?

Describe the staging (simplified):

Stage I

Stage IIA

Stage IIB

Aspirate it with a needle

Not routinely; bloody fluid should be sent for cytology

1.In the case of a second cyst recurrence

2.Bloody fluid in the cyst

3.Palpable mass after aspiration

Bilateral mammogram (cancer in one breast is a risk factor for cancer in the contralateral breast!)

CXR (to check for lung metastasis) LFTs (to check for liver metastasis) Serum calcium level, alkaline

phosphatase (if these tests indicate bone metastasis/“bone pain,” proceed to bone scan)

Other tests, depending on signs/ symptoms (e.g., head CT if patient has focal neurologic deficit, to look for brain metastasis)

Estrogen and progesterone receptors—this is key for determining adjuvant treatment; this information must be obtained on all specimens (including fine needle aspirates)

TMN: Tumor/Metastases/Nodes (AJCC)

Tumor 2 cm in diameter without metastases, no nodes

Tumor 2 cm in diameter with mobile axillary nodes or

Tumor 2 to 5 cm in diameter, no nodes

Tumor 2 to 5 cm in diameter with mobile axillary nodes or

Tumor 5 cm with no nodes

Stage IIIA

Stage IIIB

Stage IIIC

Chapter 56 / Breast 407

Tumor 5 cm with mobile axillary nodes or

Any size tumor with fixed axillary nodes, no metastases

Peau d’orange (skin edema) or Chest wall invasion/fixation or Inflammatory cancer or Breast skin ulceration or

Breast skin satellite metastases or Any tumor and ipsilateral internal

mammary lymph nodes

Any size tumor, no distant mets POSITIVE: supraclavicular,

infraclavicular, or internal mammary lymph nodes

Stage IV

What are the sites of metastases?

Distant metastases (including ipsilateral supraclavicular nodes)

Lymph nodes (most common)

Lung/pleura

Liver

Bones

Brain

What are the major treatments of breast cancer?

Modified radical mastectomy Lumpectomy and radiation sentinel

lymph node dissection

(Both treatments either /– postop chemotherapy/tamoxifen)

What are the indications for radiation therapy after a modified radical mastectomy?

Stage IIIA

Stage IIIB

Pectoral muscle/fascia invasion Positive internal mammary LN Positive surgical margins

4 positive axillary LNs postmenopausal

What breast carcinomas are Stage I and stage II (tumors 5 cm) candidates for lumpectomy

and radiation (breastconserving therapy)?

408 Section II / General Surgery

What approach may allow a NEOadjuvant chemotherapy—if the patient with stage IIIA cancer preop chemo shrinks the tumor

to have breast-conserving surgery?

What is the treatment of inflammatory carcinoma of the breast?

What is a “lumpectomy and radiation”?

What is the major absolute contraindication to lumpectomy and radiation?

Chemotherapy first! Then often followed by radiation, mastectomy, or both

Lumpectomy (segmental mastectomy: removal of a part of the breast); axillary node dissection; and a course of radiation therapy after operation, over a period of several weeks

Pregnancy

What are other	Previous radiation to the chest
contraindications to	Positive margins
lumpectomy and radiation?	Collagen vascular disease (e.g.,
	scleroderma)
	Extensive DCIS (often seen as diffuse
	microcalcification)
	Relative contraindications:
	Lesion that cannot be seen on the
	mammograms (i.e., early
	recurrence will be missed on
	follow-up mammograms)
	Very small breast (no cosmetic
	advantage)

What is a modified radical mastectomy?

Breast, axillary nodes (level II, I), and nipple–areolar complex are removed

Pectoralis major and minor muscles are not removed (Auchincloss modification)

Drains are placed to drain lymph fluid

Where are the drains placed	1.	Axilla
with an MRM?	2.	Chest wall (breast bed)
When should the drains be	30 cc/day drainage
removed?

What are the potential complications after a modified radical mastectomy?

During an axillary dissection, should the patient be paralyzed?

How can the long thoracic and thoracodorsal nerves be identified during an axillary dissection?

When do you remove the drains after an axillary dissection?

What is a sentinel node biopsy?

How is the sentinel lymph node found?

What follows a positive sentinel node biopsy?

What is now considered the standard of care for lymph node evaluation in women with T1 or T2 tumors (stages I and IIA) and clinically negative axillary lymph nodes?

Chapter 56 / Breast 409

Ipsilateral arm lymphedema, infection, injury to nerves, skin flap necrosis, hematoma/seroma, phantom breast syndrome

NO, because the nerves (long thoracic/ thoracodorsal) are stimulated with resultant muscle contraction to help identify them

Nerves can be stimulated with a forceps, which results in contraction of the latissimus dorsi (thoracodorsal nerve) or anterior serratus (long thoracic nerve)

When there is 30 cc of drainage per day, or on POD #14 (whichever comes first)

Instead of removing all the axillary lymph nodes, the primary draining or “sentinel” lymph node is removed

Inject blue dye and/or technetium-labeled sulfur colloid (best results with both)

Removal of the rest of the axillary lymph nodes

Sentinel lymph node dissection

What do you do with a mammotome biopsy that returns as “atypical hyperplasia”?

Open needle loc biopsy as many will have DCIS or invasive cancer

How does tamoxifen work?

It binds estrogen receptors

410 Section II / General Surgery
What is the treatment for	“Salvage” mastectomy
local recurrence in breast
after lumpectomy and
radiation?
Can tamoxifen prevent	Yes. In the Breast Cancer Prevention
breast cancer?	Trial of 13,000 women at increased risk
	of developing breast cancer, tamoxifen
	reduced risk by 50% across all ages

What are common options for breast reconstruction?

What is a TRAM flap?

What are side effects of tamoxifen?

In high-risk women, is there a way to reduce the risk of developing breast cancer?

TRAM flap, implant, latissimus dorsi flap

Transverse Rectus Abdominis

Myocutaneous flap

Endometrial cancer (2.5 relative risk), DVT, pulmonary embolus, cataracts, hot flashes, mood swings

Yes, tamoxifen for 5 years will lower the risk by up to 50%, but, with an increased risk of endometrial cancer and clots,

it must be an individual patient determination